In connection with employment at Hines Furlong Line (hereafter "Company"), may request a medical inquiry and/or examination for purposes of establishing and verifying the performance of essential job-related functions, with and without reasonable accommodation. I authorize and request all healthcare providers or hospitals to release said information for verification of a medical inquiry, if required, to the Company, its designated representatives, or its healthcare provider. I also understand and agree that I may be required to take a fitness for duty exam when there is a need to determine whether I am still able to perform the essential functions of the job in a safe and complaint manner.
I hereby hold harmless the Company, its officers, directors, employers, agents and assigns, for my death, any personal injury or illness resulting from, arising out of, or incurred during such test, without regard to the causes thereof or the Company's negligence, whether sole, joint, concurrent, active or passive.
I authorize a photocopy or facsimile of the Medical Information Release to be considered as effective and valid as the original. All results will be proprietary, will be kept confidential, and will not be provided to any parties other than the Company or its legal representatives, unless required to do so by court order or subpoena.
I voluntarily waive all recourse against and hereby release the requested parties from liability for complying with this Medical Information Release. The Company's retrieval and usage of this information will comply with applicable laws, rules, and regulations. The Company is an Equal Opportunity Employer and does not discriminated based upon race, color, gender, national origin, religion, age, or disability.
I further understand that the above information has been explained to me, and I fully understand its contents and applications.